By the time tragedy struck last year Depoo Hospital’s mental health staff had sent many distress signals. The Blue Paper has collected reports about staff being attacked by patients, disagreements with the police about carrying guns, understaffing, a security guard having a heart attack trying to protect staff. Finally, a patient committed suicide on camera.

She writes in her journal: Things that make me happy: Talking to Cynthia.

Cynthia is her life ring, her life partner. Thinking about her helps her get through the worst of the depression. It still works even when the doctors and the drugs fail. But this one is a big storm. Sheila is desperately trying to summon up the magic.

But there is no saving the boat that night. Mounted on the bedroom wall, the surveillance camera records Sheila getting out of bed, slowly pulling out the top bed sheet. She drags it toward the bathroom, twists it to make a knot at one end. The knot is thrown over the top edge of the door. The door closes. On the other side, Sheila is now hanging herself.

The problem is, this was not just any bedroom. This was a 24-hour a day, on camera, suicide watch section of the Depoo psychiatric hospital.

“That’s where she would go when things were bad,” says Cynthia Nathan, struggling with grief. We are sitting in the couple’s Old Town apartment. One of those Key West “good deals,” where you enter through the kitchen and a corridor is now the living room.

“She had this thing for that big tree behind Samuel’s House,” recalls Cynthia, “She kept saying, ‘I want my storm to be over,’ and I kept saying, ‘Why do you say that?’ But it was no use. She was seeing herself hanging from that tree.”

On March 15, 2016, afraid of what she might do, Sheila Belser checked herself into Depoo hospital. They knew her well there, they’d followed her through a previous attempted suicide.

It has taken us over a year to go through the process of gathering information about this tragedy. The question at the onset was how could one commit suicide while under ‘suicide watch’ in a psychiatric hospital?

What we’ve learned so far is she was put on suicide watch, monitored by nurses who were supposed to check on her every 15 minutes. There was also an in-room camera connected to a surveillance monitor. But nobody was watching.

In his investigative report KWPD Detective Stephen Mitchell finds there was a lapse of 1 hour and 15 minutes when no one checked on Sheila. At 11:35 pm, when the nurse finally entered the room, he noticed the knot over the bathroom door. When he rushed to open it, Sheila’s body fell onto the bedroom floor. The ambulance was called while nurses tried to revive her. She was pronounced dead at Lower Keys Medical Center on Stock Island.

The Director, Sandy Islands, was quick to tell Mitchel that employees would be reprimanded. In fact, the hospital fired everyone on that watch, including Sandy Islands.

Obviously, huge mistakes had been made. The routine calling for an every 15-minute check was not respected and no one was watching the surveillance monitors. However, under condition of anonymity credible sources have told us the inside story:

“Just when we’d been asking for increased staffing and security, CHS cut down the overnight staff from four to three. We now had four staff members all day but one would leave at 11:00 pm. The shift ending at 11 included an hour restocking duty from 10 to 11.”

According to our source, that fourth person was also in charge of monitoring the surveillance screens. In other words, with the new schedule in place, the hospital didn’t have anyone stationed in front of the camera monitor after 10:00 pm.

“Three weeks after that staff reduction,” said one source, “we had the first ever completed suicide at DePoo. The first ever in 30 years.”

CHS’s justification for cutting down on staff was that DePoo had been overstaffed in comparison to the number of beds the facility provided. HMA’s [CHS’s predecessor] ambitious plans to increase the number of beds at DePoo to 25 and to hire two full time staff psychiatrists had been cut down to 11 beds and three part time visiting psychiatrists.

Could this door have saved Sheila’s life?

According to another source, about a year prior to Sheila’s death, DePoo administrators were advised that the tops of the bathroom doors should be cut short to prevent patients from using them to hang themselves. We were able to verify that shortened, sloped doors are indeed the modern standard for psychiatric wards. “What I heard,” said our source, “is that they claimed they did not have the money [to crop the doors].” The doors have now reportedly all been replaced.

Lower Keys Medical Center responded to our request for comment stating they were profoundly saddened by the death of the patient and that they had taken all appropriate actions. [The full statement is below this article.]

But one of our sources describes the working conditions at DePoo, since Sheila’s death, as “horrible ” and ” demoralizing.” “They blamed the staff for everything that happened.” Apparently CHS has put video cameras everywhere to monitor the staff but has removed the monitors that allowed staff to view the patients’ rooms. “They said we were relying on the patient monitors too much.”

“This exposes us even more,” said one source, “at least with the in-room camera monitors we could tell a coworker, ‘I’m going into so and so’s room. Keep an eye out.’”

“Some of the patients have attacked the staff. At night, there are only three women monitoring that floor. They’ll bring us people discharged from the jail. Some of those people have been brought under control at the jail by being tased and sedated. And we go, ‘what is he going to do when he wakes up?’”

“A month before Sheila’s death the staff fought for 45 minutes to restrain a delirious patient. Some staff were injured. The security guard suffered a heart attack. We’d been ordered not to call the police – because of the dispute over bringing guns into the psychiatric ward. We called them anyway. After that, we asked for one more security guard. Instead, CHS reduced the staff and three weeks later a patient hung herself. If we can’t keep ourselves safe, how can we keep our patients safe?”

Finally, Cynthia says she was certain something was wrong with the way Sheila was medicated at DePoo: “Every time she’d come back she’d be a different person. They would mess with her meds and let her out after 2 days. One time she came back and she was an artist. She was sketching and coloring all the time, where before she couldn’t draw a stick figure! That was weird! Or she’d just feel worse. I kept saying they need to adjust your meds better. The last time she came back she was talking about suicide all the time.”

“I feel so bad. We still had hope. There was still a glimmer of hope,” says Cynthia. They were an odd couple. Two women over 40. One white, one black. They had met through the tribulations of homelessness in Key West. With no particular skills, they struggled for months to get their own little apartment together, both dogged by a history of depression. But through a life of night jobs and dishwashing they had fallen in love. “It was not much but there was still a little glimmer of hope.”

“Our entire team has been profoundly saddened by this patient’s death, and we extend our deepest sympathies to the patient’s family.

The hospital initiated an immediate and extensive internal review into the circumstances of this patient’s death and all appropriate agencies were notified. We worked closely with regulators to ensure ongoing access to the critically important behavioral health services we provide for this vulnerable population.

Due to federal privacy guidelines and out of respect for the patient’s family, the hospital is not able to provide any further information. “

[NOTE: DePoo Medical Center and the Lower Keys Medical Center on Stock Island are part of a single hospital system. Both facilities are run by CHS [Community Health Systems].]

Arnaud and Naja Girard, owners and editors of the new, digital, Key West the Newspaper (The Blue Paper) previously reported for the former Key West The Newspaper, Key West’s longest running independent weekly, published by Dennis Reeves Cooper, Ph.D., from January 1994 until November 2012. The Girards are perhaps best known for their discovery of and extensive research surrounding the US Navy’s 1951 claim of ownership of Wisteria Island but are also responsible for top investigative stories including breaking news coverage of the highly controversial in-custody-death of Charles Eimers on Thanksgiving Day 2013, the catastrophic police tasing of Matthew Shawn Murphy, and the property tax scandal involving Balfour Beatty to name a few. Arnaud and Naja have lived in Key West since 1986.

“From 2,429 suicides and 50,323 controls, they found that taking psychiatric medication made a person 5.8 times more likely to kill themselves. Psychiatric outpatient contact increased the suicide rate 8.2 times. If the person had visited a psychiatric emergency room they were 27.9 times more likely to kill themselves, and if they’d actually been admitted to a psychiatric hospital they were 44.3 times more likely to commit suicide.”

This persons death is the resultant byproduct of corporate’s obsession with profit. The word “enough” is an anathema to the criminal capitalist. Greed is a virtue in their world and “other’s” pain or death is just part of doing business. This stance has become the norm in this fading republic.Disgusting

Great digging, investigating and reporting. Terrible indictment. I think Alex Symington summed it up. I myself have serious trouble feeling good about a lot of what psychiatry does. In this case, though, it seems no psychiatrist is running or oversighting the running of De Poo? I wonder, this really ain’t politically correct, if the tortured soul who hung herself is happier where she now is? I hope so, because she apparently was miserable being alive and apparently was not getting help with it, and/or was getting help she could have done without, all based on the blue paper article.

“How stupid and perverted are our medical people to base a medical system on a man named Sigmund Freud, who stated that man’s natural instinct was to murder his father so as to have sex with his mother?! He also said that babies are “orgasmic”. This is against all natural instincts and the natural order of creation. It is all lies.”